The Role of Pain Management
In the treatment of Persistent Pain
Barbara Sharp
Lead Clinical Specialist Physiotherapist,
Dr. Isla McMakin,
Clinical Psychologist,
Pain Management Team, RCHT,
Cornwall
Can we fix it? Yes we can!
Then why do some patients:
- Keep coming back?
- Seem so miserable?
- Have high expectations; unrealised?
- “Doctor-shop”?
- Bring vocal friends & family to the consultation to
ask awkward questions?
- Write long letters describing how awful their pain
is?
- Still have pain even though the
operation/injection is a “technical success”?
A Pain Story
Adapted from Appendix D “What can you say about pain”
Wendy Edey, Rachel L. King, Denise J. Larsen & Rachel Stege (2016) The “Being Hopeful in the Face of Chronic
Pain” Program: A Counselling Program for People Experiencing Chronic Pain, The Journal for Specialists in
Group Work, 41:2, 161-187, DOI:10.1080/01933922.2016.1146378
To link to this article: http://dx.doi.org/10.1080/01933922.2016.1146378
Published online: 03 Mar 2016
Beliefs about Pain – drives treatments?
With thanks to Mike Stewart – ‘Know Pain’
fMRI brain involvement noted during acute &
chronic pain experiences:
• Anterior cingulate cortex (ACC)
• Amygdala
• Periaqueductal grey
• Anterior insula
• Nucleus accumbens
• Primary & secondary
somatosensory cortex
• Posterior insula
• Thalamus
• Medial pre-frontal cortex
• Parahippocampal gyrus
= Pain Matrix
How do we respond
to someone in pain?
As Clinicians we often feel we must ‘do something’:
• Physiotherapists will give exercises & activity
advice
• Medics will provide medication and interventions
• Occupational Therapists will adapt functional
activities
• Psychologists will consider behaviour and
cognitive models of treatment
• Nurses will offer practical support and care
It is difficult to do nothing; offer nothing; we may feel
we are their only hope? We are trained to offer more
than sympathy; we are compassionate people
(usually!).
Can we empathise or is that too uncomfortable, for
us?
Do we feel a failure and find it easier to blame the
patient for their failure to recover?
Can we draw a line in the proverbial sand & say, no
more ‘passive’ treatments, there is nothing else?
Pain Experience; an output of the brain
Pain is so
much more
than wear &
tear or a
squashed
nerve
If we can’t stop the
nociceptive barrage – or
there is no nociceptive
barrage – how is a local,
physical treatment going to
help?
How can I be worn out, I’m
only 30 years old?
Time Lines & Expectations
Healing times & their relationship with pain…
-
E.g. do discs heal?
-
What do you believe?
Modelling acceptance & recovery
-
If you show significant concern about the levels of pain
and keep searching for the cure, what will this do for
the person with pain?
-
Encouraging movement while pain is present requires
confidence - for the prescriber as well as the patient
Nurturing hope while creating realistic expectations
-
Pain is complex and so are people;
-
not everyone can compete in the Invictas Games.
-
The body deteriorates if it is not used: form follows
function….
So What is Pain Management?
group support
normalising
Pain Education
graded exposure
CBT
laterality
ACT
desensitisation
CFT
mirror therapy
mindfulness
rehabilitation
imagery
reablement
relaxation
pacing
learning
activity management
biofeedback
values
coping
goal setting
meditation
discrimination
awareness
re-training
acceptance
confidence
motivation
stress management
sleep
listening
behaviour change
empathising
Referrals in Cornwall to Chronic (Persistent)
Pain Management Team
1. GP – sets the bar
1. Physiotherapy/AQP – offers hope; dashed?
2. ESP – ‘specialist’ – offers hope; dashed?
3. Consultant(s) – ‘Super-powers’ – offers hope; dashed?
2. Pain Management; sold as ‘last resort’? no hope,
poor expectation?
•
•
How many years after pain onset?
How much could have been taught nearer the
beginning?
We need to know:
1.
2.
3.
4.
Diagnoses (Pain Clinic is not a diagnostic service)
Previous Interventions (including meds, ops, MH)
Expectations – yours and there’s?
Mood (present and past mental health status including
drug and alcohol misuse)
5. Social history; work, rest and play.
6. Pain Management Team
1.
2.
3.
4.
5.
6.
Referral vetting; further information may be required
Joint appointment (physiotherapist & psychologist) – treatment
plan agreed
Introduction to Pain Course (1 x 2hrs) in community venue
Pain Management Course (PMP) 9 + 2 x 2.5hrs in community
venue or
Individual sessions or
Signposting (especially mental health Ix & Rx)
Struggle or Accept?
References, Watching & Reading
• 2015, CSPMS Core Standards for Pain Management Services in the UK, Faculty
of Pain Medicine
• 2014, Flor, Herta. Psychological Pain Interventions and Neurophysiology.
American Psychologist Vol 69. 2; 188-196
• 2013, Pain Management Services, Planning for the Future, Guiding Clinicians
with their Engagement with Commissioners, Royal College of GP’s
• 2017, Zhong, M., et al. Incidence of spontaneous resorption of lumbar disc
herniation; a meta-analysis
• http://www.csp.org.uk/your-health/conditions/chronic-pain
• Explain Pain e.g.
–
–
–
–
–
–
Brain Man: https://www.youtube.com/watch?v=jIwn9rC3rOI
Lorimer Moseley: https://www.youtube.com/watch?v=5p6sbi_0lLc
David Butler: https://www.youtube.com/watch?v=4ABAS3tkkuE
Mick Thacker: https://www.researchgate.net/profile/Mick_Thacker
Jo Nijs: https://www.youtube.com/watch?v=_o02m2XdRmc
Louis Gifford: 2015, Aches and Pains (3 book set) https://giffordsachesandpains.com/booksales/